IPPNW European Student Congress Napoli May 2006

Enduring effects of war: health in Iraq Photo: Doctors for Iraq

 “We have opened the Pandora’s box and the question is what is the way forward?” US ambassador to Baghdad Los Angeles Times 7 March 2006  81% of households lack proper sanitation 68% lack access to potable water Special Inspector General for Iraq Reconstruction January 2006  “Doctors fear to be attacked by the occupying forces and…many times cannot attend…due to road blocks and curfews…” medical student Ramadi Iraq Communique Summer 2005

Medact UK charity for global health highlights the health impact of violent conflict, poverty and environmental degradation membership organisation of health professionals UK affiliate of International Physicians for the Prevention of Nuclear War (IPPNW)

Medact: work on conflict and health health costs of Gulf War psycho-social work in former Yugoslavia improving refugee health in the UK seminars on reconstruction of health system in Afghanistan impact on health of war on Iraq: reports 2002; 2003; 2004 updates July 2005; March 2006

Medact: work on conflict and health 2004 Report: enduring effects of war: health in Iraq

Medact reports on Iraq: why? to stimulate debate on health effects of war to hold government to account to assess the adequacy of reconstruction efforts to use health data to help prevent war

Medact reports on Iraq: how? desk studies interviews with a range of people working in Iraq 2004 report: visits to Amman wide dissemination through IPPNW affiliates and media

Medact reports on Iraq: how? multi-skilled research teams panel of expert advisors funding from Oxfam (GB), Lionel Penrose Trust and Polden-Puckham Charitable Foundation

Medact reports on Iraq: how? Role of students and doctors 2002 Iraq report: research by Catherine Ford and Robert Henderson, medical students on international health course 2003 Iraq report: researcher and author Dr Sabya Farooq, epidemiology and public health masters graduate 2004 Iraq report: researcher and editor Dr Trishan Panch physician, international health consultant 2004 Iraq update: researched and written by Tom Yates, medical student 2005 Iraq update: researched and written by Kingston Reif, US international relations graduate; MSc intern in UK

Medact reports on Iraq: constraints inadequate baseline data lack of information denial of information war and aftermath

Situation before war on Iraq Gulf War; sanctions; Saddam Hussein’s regime dramatic “break” in health improvement after 1990 decline in functioning of health system decline of health-sustaining infrastructure increase in poverty increase in corruption health of population very vulnerable to new war collateral damage: the health and environmental costs of war on Iraq Medact 2002

Overall picture since 2003 war Casualties of war and aftermath Combatant: Iraqi Deaths: 13,500-45,000 estimate Injuries: 40, ,000 generally calculated x3 number of deaths Combatant: coalition Deaths: 2,428 (US); 109 (UK) 111 (other) Injuries: 17,869 (US) Iraq Coalition Casualty Count 10 May 2006

Combatant injuries Iraqi combatants: no information available Coalition combatants US: survival rate 90% (WWII 70%, Vietnam 76%) 6% required amputations 20% have suffered head and neck injuries at least 1,700 brain injuries: estimated long term cost of treatment $14 billion UK: 230 injured: 12 required amputations January have suffered paralysing injury, loss of eye or brain damage January 2006

Casualties of war and aftermath Iraqi civilian deaths 98,000 excess deaths estimated from nationwide cluster sample survey September Roberts et al ,258 reported maximum Iraq Body Count 10 May 2006 Average violent deaths per day rising: Iraq Body Count 20 March 2006 Year 1 post-combat20 per day Year 2 post-combat31 per day Year 3 post-combat36 per day “30,000 more or less” Iraqi civilians dead President George Bush The Washington Post December

Iraqi civilian deaths Photo: Doctors for Iraq

Weapons used by coalition in combat cluster weapons: unexploded bomblets causing child deaths and injuries depleted uranium: general health risks unclear; cancer risk from inhaled particles napalm bombs; white phosphorus Geneva Convention Protocol 1 prohibits indiscriminate attacks, use of indiscriminate weapons especially in built up areas; prescribes protection of civilians question of legality of use of these contentious weapons

Cluster bomb injury Photo: Doctors for Iraq

Decline in health of population rise in deaths from all causes since invasion substantial increase x58 in risk of death from violence high child mortality; 50% children malnourished high maternal mortality; reported rise in back street abortion vaccine preventable disease preventable child deaths from diarrhoeal disease, acute respiratory infection: 70% child deaths in 2004 rise in mental health and social problems

Living amidst conflict crisis of law and order: insecurity and fear insurgency & sectarian violence; threat of civil war crime; kidnappings detention of 15,000 Iraqis by US + allies March 2006 ; 12,000 by Iraqi authorities November 2006 torture and killings

Living amidst conflict women and girls threatened: rape; human trafficking education severely disrupted surges in internally displaced people health and aid workers targeted

Mental health Civilians impact of estimated 50% unemployment increase in anxiety and mood disturbance longer term: expected increase in suicides, drug and alcohol abuse, social and domestic violence almost no mental health services increased behavioral and learning problems in children and adolescents

Mental health “The only things they [Iraqi children] have on their minds are guns, bullets, death and a fear of the US occupation” Association of Psychologists of Iraq, February 2006 children suffer fear of kidnapping and explosions 92% found to have related learning impediments report of Association of Psychologists of Iraq, 5 February 2006

Mental health Photo: Doctors for Iraq

Mental health Combatants up to 1/3 returning US troops suffer mental health problems (estimated 40,000) or marriage problems returning US soldiers: higher incidence of post traumatic stress disorder than in Vietnam or first Gulf war by January US troops were reported to have committed suicide

Health sustaining infrastructure reconstruction faltering: funding falling; corruption; 25% - 50% of funds spent on security water and sanitation facilities damaged and looted power network extensively damaged and looted water and electricity key for nutrition and functioning of health system: supply well below pre-war level majority depend on food baskets under Public Distribution System

Health sustaining infrastructure Photo: Doctors for Iraq

Health system all activities to promote, restore or maintain health WHO

Health system “Imagine yourself trying to operate on a patient in a two- hour surgery and the power goes out… You pray to God, and you sweat” Dr Waleed George, May 30, 2005

Health system Photo: Doctors for Iraq

Health system destruction; looting; 90% hospitals needed repair or reconstruction March 2005 large increase in funding but still low: $38 per capita in 2004 corruption; medical supplies diverted increase in pay for health workers: but low relative to rising cost of living overwhelmed by surges in violence the system struggles to function…

Health system lack of basic supplies: patients purchase drugs & supplies from black market widespread commercialisation: twice as many Iraqis use private services than public services constitution pro-privatisation lack of capacity of Iraqi Ministry of Health lack of coherent Iraqi health policy inequities in distribution of health facilities

Health system doctors & health workers attacked, shot at, threatened & told to leave or die 2,000 physicians murdered since 2003 estimate 65 doctors killed in physicians kidnapped since invasion estimate 34,000 registered physicians before invasion; 12,000 have left since due to security situation medical care and access to medical care impeded by military operations breaching of medical neutrality

Baghdad medical teaching facility Photo: Doctors for Iraq

Relief and reconstruction no plan pre-invasion for health reconstruction UN marginalised then bombed confused relationship between military and humanitarian actors Coalition Provisional Authority did little: a lot of money was spent but much unaccounted for only 30% of Madrid Conference pledges received hampered by violence

Reconstruction “We were never intending to rebuild Iraq…. We were providing enough funds to jump-start the reconstruction effort in this country.” Gen. William H. McCoy commander US Army Corps of Engineers, January emphasis on reconstruction of hospitals and clinics rather than how they would function £1.1 billion profits made by British construction and security firms USAID cancelled contract with US healthcare company because of incompetence

Conclusions death and injury of tens of thousands of Iraqi civilians and combatants numbers rising 2003 war exacerbated damage to health of Iraqis from previous wars, former regime, and sanctions immediate impact of conflict on health represents a small proportion of the longer term suffering security crisis; collapse of state; continuing violence; threat of civil war health system in crisis with rising demands; poor progress in reconstruction; health workers targeted; skills drain

Medact: key recommendations Independent inquiry an independent commission should make a thorough investigation of casualties and the state of health in Iraq since the invasion in 2003 Count the Casualties Campaign

Medact: key recommendations Protecting health in conflict require occupying forces to: comply with the Geneva Conventions monitor casualties and civilian protection re-evaluate the impact of weaponry in populated areas ensure health services are accessible to civilians in conflict areas and the protection of health workers

Medact: key recommendations Longer term interventions to improve health and build peace: strengthen stewardship role, capacity and funding of Iraqi Ministry of Health to rebuild an Iraqi health system based on primary health care principles moving away from charges at the point of delivery to fully tax-based system role of health system in nation building and building peace

Further work by Medact monitoring of health in Iraq: update on Iraq health situation Communiqué March 2006 proposal for 2006 reporton health in Iraq development of an advocacy programme, using health impact of violent conflict in prevention of war, and upholding of rule of law

Further work by other organisations Iraq Body Count press release on civilian casualties 9 March 2006 Crisis Action: Medact collaboration on health risks of potential attack on Iran IPPNW appeal to Kofi Annan to set up a mediation commission on Iran

Postscript: "what one person can change" NGOs working in conflict and health : opportunities for students, young doctors, public health specialists as volunteers or in project work analysis authorship editing testimony advocacy campaigning